Implementing ED grief programs pose unique challenges
Other departments may have two or three days to build a rapport with a patient's family, the ED staff has maybe half an hour
When an infant and young man died tragically in the same week at Loma Linda (CA) University Medical Center's ED, nurses were at a loss to help grieving family members. On the day of the boy's death, the only place to put the boy's body was the utility room, recalls Jan Taylor, RN, SCM, ONC, who implemented the ED's grieving program. "It was a friend of my son's, so to see this child laying in there hit home on a personal note," she says.
At first, Taylor tried to incorporate the hospital's existing grieving programs, but soon realized the ED posed its own unique challenges. "In other departments, caregivers might have one or two days to build a communication with the family, whereas in the ED you only have half an hour," notes Taylor.
Working with donated funds, the ED staff decorated a room and named their fledgling grief program SEASONS for Sensitive Emergency Approach to Significant Others' Needs in Sorrow. A logo was designed to signify the four seasons, and a folder was created with informative booklets appropriate to the situation.
"Family members won't be able to absorb anything you give them at the time, but they can take it home and read it later," explains Taylor.
The booklets, available in both Spanish and English, contain information about chaplain services, funeral arrangements, and support groups. "When we give them the package, a nurse fills out a data collection form that lists the next of kin and describes what measures were offered at the time of death," Taylor says. (See grief record form, page 90.)
The form is given to the grief program counselors, who send a bereavement card signed by everyone involved in the patient's care. Two weeks later, a letter is sent from the ED's grief counselors that invites the family members to call if any further interventions or financial support are needed. The letter is followed by a telephone call. (See grief counselor follow-up form, page 91.)
Twice a year, a memorial service is held for patients who have died in the hospital. "Then, on the next significant holiday, we send a card, and then hopefully after all those interventions, we can sever the ties," Taylor explains. "We try not to keep contact any longer than a year, because otherwise the family member can get dependent on the counselors."
The interventions may even save lives. When one man threatened suicide during a phone call with a grief counselor, police were notified. "They found he had taken an overdose, but was still alive," says Taylor.
Counselors also helped a 13-year old girl whose father had died in the ED. "Before she had left the house that day, she said, "I wish you were dead," like a typical teenager. And when she got back, she found her father had shot himself in the head," Taylor recounts. "The child happened to pick up the phone when I called, and she broke down crying, saying she'd killed her father. She was carrying around a tremendous amount of guilt, so we got her into support groups."
Grieving family members may find it easier to confide in a stranger. "They may feel bad discussing it with their family because they don't want to burden them with their feelings," says Taylor.
The program also benefits the ED staff, Taylor notes. "Before, nurses felt badly about family members leaving without any support, because they didn't get the same interventions as the families of inpatients did," she says.
Help families cope with sudden death
Unexpected deaths are a reality in every ED, but often, too little time or attention is spent on helping family members cope with tragedy. "In a busy ED, taking care of family members who have lost a loved one can be so easily overlooked," says Cindy Edwards, RN, BSN, CEN, the ED's clinical unit educator at Spartanburg (SC) Regional Medical Center. "It's so important to try as hard as you can to meet their needs."
Here are some suggestions to help family members during a crisis.
Have a representative just for the family. The ED at the Methodist Hospital in Houston has a staff member whose role is to assist patients and family members, which includes helping them grieve. "We help them get in touch with other family members, contact funeral homes, notify the chaplain, or just give them a warm blanket and a cup of coffee," says Antoinette Wilturner, the ED's patient information representative.
The idea is to provide some of the comfort that may be lacking in the hectic ED environment. "It was something that was always missing before," Wilturner says. "Sometimes a family member is so overcome they can't speak, and they just need to cry and lean their head on your shoulder."
Allow family members time. At the Methodist Hospital, the ED staff makes sure a distraught family member stays in the ED as long as is needed. "Before they leave, we make sure they're OK; we won't send them home in a crisis situation," says Wilturner.
Make the family an extended patient. At Spartanburg (SC) Regional Medical Center, family members are assigned a nurse to help them through the crisis. "They become the extended patient," says Edwards. "We'll make phone calls for them, arrange lodging, or, if it's the middle of the night, they may need something as simple as coffee," says Edwards.
However, the main benefit is to provide moral support," says Edwards. "It's mainly just being there for them. Sometimes all they need is someone to sit and hold their hand and cry with them."
If the primary nurse is overwhelmed with patients, the charge nurse stays with the family, she explains. "When you have a 10-car pileup, and all the nurses are taking care of patients, the one with the least critical patient will stay with the family members."
Family members often get in touch with ED staff long after the crisis, to let them know what a difference their efforts made. "One mother sent us a plaque with an artist's sketch of her son after he became an organ donor, letting us know how much our nurses helped her through it," says Edwards.
Refer family members to other sources of support. At Spartanburg, parents are always referred to support groups. "The death of a child is a whole different world, and we refer them to our hospital's social worker," says Edwards.
Chaplains are on call 24 hours a day. "When we have a code for a multi-trauma patient, the chaplain is automatically called, and they respond immediately," says Edwards.
Keep in touch with family members when possible. Although it's often impossible to spend much quality time with patients in a busy ED, Spartanburg's emergency nurses make a practice of bonding with families and have even attended the funerals of patients. "During a crisis, the family becomes ours, and we take them in as our own," says Edwards.
Honesty is the best policy. Nurses should be honest with family members and prepare them for the likelihood of death. "Families don't need to sit out there and wait for an hour, having no idea what's going on, while we're working to save a life, believing their loved one is going to be saved," says Jeri Foley, RN, BSN, TNCC, CEN, an ED nurse at University Hospital in Cincinnati. If there are extra nursing personnel, they should step out of the room and let the family know if things aren't looking good, she adds.
Decide whether to allow family members to be present during resuscitation efforts. Many nurses say allowing family members to witness attempts to save a loved one's life can help with the grieving process, whatever the outcome. "Family presence during the resuscitation can help start the grieving process in a healthy way," says Foley.
Make your presence known. Some nurses make a habit of accompanying the physician as he or she informs the family of a death. "Often, the physician will do all the talking, but, even if I don't say anything, just the fact that I'm present in the room can be comforting," notes Foley.
Send a sympathy card. At Corning Hospital, a bereavement card is sent out approximately four weeks after a patient's death. "To send it out immediately after would be too much, when they are dealing with lawyers and arrangements with out of town family members," says Sheila McFall, RN, CEN, the ED nurse who designed the card. "We try to catch up with them when things begin to settle down. "This is a way of trying to mend the seams so these people don't fall through the cracks."
After McFall obtained approval from the director of nursing, she wrote a poem titled "Thinking of You," and the hospital agreed to pick up the cost of printing the cards. "The cards are hand-addressed so it doesn't give the appearance of a form," she notes.
To make sure no grieving family members are overlooked, the ED nurses go through the monthly log on a regular basis. "Sometimes there is a patient who does make it up to ICU, so that won't show up on our ED log," says McFall. "The upstairs nurses are encouraged to write our nurse manager a note and leave it on desk, to let them know that a card should be sent out."
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